!: CMS - Medicare PECOS Ruling May Affect Payments by Medicare

CMS originally had a deadline of July 6, 2010 for all ordering and referring providers to be enrolled in the PECOS system, or the Provider Enrollment, Chain and Ownership System but in the June 30th news release they announced that they will not be making the changes that will automatically reject claims based on ordering or referring providers who have not yet had their PECOS applications approved. What does all of this mean?

Well it's actually good news for any providers who order services or refer patients enrolled in Medicare, and have not enrolled yet in PECOS. Basically if a provider has not enrolled in Medicare or submitted changes or updates to their Medicare Information in the past 6 years, then they probably are not enrolled in PECOS. If a provider has enrolled or submitted changes/updates in the last 6 years, then they should be already enrolled in PECOS. The Medicare contractor would have automatically input the application into the PECOS system, even if they submitted a paper application.

So if the provider has been enrolled in Medicare longer than 6 years and has not submitted any updates or changes, then they still need to enroll in PECOS. The PECOS system can be accessed at the Medicare website. They should use their NPI login username and password to access the system.

CMS has been encouraging providers to use the PECOS system to enroll in Medicare or submit any updates or changes to their Medicare information for quite a while. Now they are mandating the use of PECOS by denying any claims for services that were ordered or referred by a Medicare provider who is not enrolled in the PECOS system. This makes things tough because the provider submitting the claim cannot control if the ordering or referring provider has enrolled in PECOS. This may be why they announced that they would not make the changes that would result in the denial of claims that were ordered or referred by providers not enrolled in PECOS.

At some point, this mandate probably will be implemented so it really is in a provider's best interest to make sure they are compliant. If you do not know if you or your provider is enrolled in PECOS then you should check. There is a national list available. It has the names and NPI numbers of all providers in the US who are enrolled in the PECOS system. You can check that list to see if you or your provider is enrolled. You can also call the local Medicare carrier provider enrollment line and ask if you or your provider is already enrolled.

If you or your provider is not enrolled you will either need to enroll by completing the application online through the PECOS website, or by submitting a paper enrollment application re-validating the information, even if nothing has changed. I would suggest that you don't wait until claims do start to get denied. If you are a billing service you should check the list for all of the providers you bill for and advise them if they are or are not all set. If they are not, you should advise them what needs to be done.

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